DI 81020: DDS Procedures - Electronic Process
TN 4 (03-09)
A. Definition of Medical Reactivations
Medical Reactivation changes a claim that is in “closed,” “transferred,” or “manually cleared” status in the electronic folder to “pending” or active again. Medical Reactivation is only permitted on a claim with a medical determination in the most recently closed Certified Electronic Folder (CEF) case. A case is defined as all of the claims filed/adjudicated at the same time.
B. Identifying possible Medical Reactivation
A claim is Medically Reactivated in eView so that the prior medical decision can be reopened. The policy regarding reopening and revision has not changed.
Follow the existing reopening policies and procedures in:
DI 27501.005 – Reopening and Revising a Determination or Decision
DI 27505.001 – Reopenings and Revisions: Pertinent Definitions and Related Policy
DI 28500.000 – Reopenings and Revision of CDR Determinations
NOTE: Use of Medical Reactivation is controlled by position and security profile. FOs, DDSs, Data Processing Branches (DPBs) and Federal Division Unit (FDU) are able to designate specific individuals who medically reactivate cases. The DDS and DPB must request that functional profile P73680P is assigned to the individual(s) by the Regional Center for Security and Integrity. The FDU must request that functional profile P73680P is assigned to the individual(s) by the Office of Central Operations (OCO) Center for Security and Integrity.
Medical Reactivation may be used when there are no open claims pending in EDCS or eView and:
Trailer mail is received that affects the final decision.
The FO detects an error on the 831 such as an incorrect regulation basis code, onset date, etc. and verifies with the DDS, DPB or FDU that the claim should be reopened.
The FO revises pertinent factors in the case such as the insured status dates or provides a statutory blind date last insured, etc. and verifies with the DDS, DPB or FDU that the claim should be reopened.
The DDS, DPB or FDU makes a favorable decision with evidence that is readily available, but needs to develop for an earlier onset.
C. Reactivating claim
When there are no current pending or open claims for the same person in EDCS or eView, claims in the most recently closed Certified Electronic Folder (CEF) with a medical determination can be Medically Reactivated.
1. Medical Reactivation using eView
To reactivate a claim:
Enter the SSN on the Case Selection screen and select the claim to reactivate;
NOTE: Remember the claim must be in the most recent CEF case and have a status of “closed,” “transferred,” or “manually cleared.” Reactivation only works when there are no pending cases in eView.
Lock the claim using “Edit (Lock Case)” in eView;
Click on the Case Status/History tab;
Click “Reactivate” on the Case Status/History screen. The Reactivate Claim screen will display claims available for reactivation;
Select the claim to reactivate, and
Key the reason why a Medical Reactivation is needed.
For example: developing for an earlier onset date, FO modified the date last insured, or Incorrect Regulation Basis Code on 831 dated xx/xx/xx, SGA establishes a different onset date, etc.
NOTE: The FO must contact the DDS, DPB or FDU before they send a Medical Reactivation to the DDS, DPB or FDU. The DDS, DPB or FDU must agree with the FO to medically reactivate the claim.
2. A claim is Medically Reactivated by mistake
If a claim is medically reactivated by mistake users have the ability to cancel the medical reactivation:
FO users must cancel the medical reactivation using EDCS by going to the “Claims Actions” tab and choosing “Cancel Reactivation”. The FO cannot cancel a Medical Reactivation through eView; and
DDS, DPB or FDU users receipt the claim and close it as a “No Decision” and select the reason “Mistakenly Reactivated in their case processing system.
D. Processing Medical Reactivations in the DDS
1. Case receipt
The DDS, DPB, or FDU receives an EFI download and the claim appears in the EFI download queue. There is no paper associated with the medically reactivated claim.
Take the following steps to receipt case:
Receipt all medically reactivated claims in NDDSS with a level of RO (Reopening), and
Assign the claim(s) to the examiner.
Typically this is the same examiner who made the first determination.
NOTE: Do not use the DUPD/RTN process to receipt medically reactivated claims unless they are sent by OQP during the quality review process.
2. Case development
Once the claim is assigned to an examiner, the examiner can work the claim just like any other CEF claim.
If the examiner makes a new determination, prepare an SSA-831 (DISABILITY DETERMINATION AND TRANSMITTAL) SSA-832 (CESSATION OR CONTINUANCE TITLE XVI), or SSA-833 (CESSATION OR CONTINUANCE OF DISABILITY OR BLINDNESS DETERMINATION AND TRANSMITTAL) per normal reopening procedures. See Completion of Form SSA-831-U5 in Title II Reopening Cases - DI 27530.015 and Completion of Form SSA-831-U5 in Title XVI Reopening Cases - DI 27530.025.
The determination is added to the CEF and the FO is alerted on the EDCS Actions Page for necessary FO action.
If the examiner decides there is no change to the original Determination (ND); he or she selects an ND reason through their case processing system “Original Decision Not Changed.” Since there is no additional action for the FO to take, the FO does not receive an alert on the EDCS Action Page. See Processing “No Determination” Claims - DI 81020.127.
E. Appeal filed on a Medically Reactivated claim
If an appeal is filed at the FO while a medical reactivation, a medical reactivation involving a possible reopening, or a subsequent claim medical reactivation, is pending at the DDS, the FO provides notification of the appeal to the DDS via an SSA-5002 (Report of Contact) and a telephone call. The DDS:
closes the claim with a No Determination with reason “No Decision Change” (NODC). See Processing “No Determination” (ND) Claims - DI 81020.127; and
sends the claim to case closure.